Side Effects of Verbal Cueing and Interventions to Alter Gait Deviations: Difference between revisions

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|Wearable with vibratory feedback at appropriate cadence
|Wearable with vibratory feedback at appropriate cadence
|-
|-
| rowspan="3" |late heel off or delayed heel off, insufficient ankle plantarflexion and terminal stance phase.
| rowspan="3" |'''Late/delayed heel off'''
| rowspan="3" |
| rowspan="3" |
* Anterior hip pain
* Anterior hip pain
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|Auditory
|Auditory
|“spring in your step”
|“spring in your step”
|Listen to verbal cues: “yes”; “dampen it”; “need more effort”
|Listen to verbal cues provided: “yes”; “dampen it”; “need more effort”
|-
|-
|Kinesthetic Tactile
|Kinesthetic Tactile
|Feel heel lift off ground sooner
|Feel heel lift off ground sooner
|Use of elastic tape
|Use of elastic tape
|-
| rowspan="3" |'''Too much toe out'''
'''(more than 15 to 20 degrees of the foot progression angle)'''
| rowspan="3" |
* Hip osteoarthritis (OA)
* Knee OA
* Can continue after a total joint replacement
* Patellofemoral arthralgia
* medial tibial stress syndrome
* Achilles pain
* Plantar heel pain syndrome
* pain on the ball of the foot
* Metatarsalgia
* hallux limitus
* Great toe OA
* Bunions
|Visual
|Visualise your foot as a front car tire, keep it straight down road
|Align foot with tape or line on ground
| rowspan="3" |
* Potential adverse effect with intention increase of toe in is a decreased knee adduction moment and an increased knee flexion moment
* For patients status post total knee replacements with weak quadriceps, may experience knee pain
|-
|Auditory
|Listen to verbal cues provided: “yes”; “dampen it”; “need more effort”
|Say out loud "turn foot inward"
|-
|Kinesthetic Tactile
|Push heel outward or turn toe inward
|Touch or tap the muscles on front of hip, "use this muscle"
|-
| rowspan="3" |'''Lateral pelvic drop, contralateral pelvic drop'''
| rowspan="3" |
* Back pain
* Hip labral problems
* Gluteal tendinopathy
* Piriformis syndrome
* Patellofemoral arthralgia
* IT band syndrome
* Medial tibial stress
* Ankle pain
* Achilles pain
* Plantar heel pain syndrome
|Visual
|Imagine pelvis is bucket of water, don’t let water spill out
|
* Walk towards mirror,  watch belt and keep it level
* Laser light target
| rowspan="3" |Muscle fatigue and soreness
|-
|Auditory
|"Image pelvis is bell, quiet the clang of the bell"
|Listen for foot strike make sound symmetrical and rhythmic
|-
|Kinesthetic Tactile
|Touch hand to gluteal muscles, "engage this muscle"
|
* Hip spica brace
* Neoprene sleeve
* Nonelastic or elastic strapping of hip
|}   
|}   




Cognitive overload can occur when a person is being challenged mentally by the therapeutic interventions.  They are processing  too much information or too many tasks, and it adversely affects their motor learning process.  The rehabilitation professional can modify this overload by: (1) discontinuing the intervention, (2) continue the intervention and encourage the patient through the task, (3) modify the task from the whole into smaller steps or parts, (4) or modify the intervention by switching the sensory preference of the verbal cue being provided to the patient.<ref name=":0" />  
Cognitive overload can occur when a person is being challenged mentally by the therapeutic interventions.  They are processing  too much information or too many tasks, and it adversely affects their motor learning process.  The rehabilitation professional can modify this overload by: (1) discontinuing the intervention, (2) continue the intervention and encourage the patient through the task, (3) modify the task from the whole into smaller steps or parts, (4) or modify the intervention by switching the sensory preference of the verbal cue being provided to the patient.<ref name=":0" />
 
The next gait deviation I want to talk about is the gait deviation of too much toe out, more than 15 to 20 degrees of the foot progression angle. And that's associated with the musculoskeletal pain syndromes of hip osteoarthritis, and it may be continuing after they have a normal hip as a habit. The same is true for knee osteoarthritis. This is a frequent gait deviation that's an automatic compensation for the knee pain contributing to the knee osteoarthritis, and it can continue once the knee is a good joint as a habit. It also is present with patellofemoral arthralgia, medial tibial stress syndrome, Achilles pain, plantar heel pain syndrome, pain on the ball of the foot, metatarsalgia, hallux limitus, or big toe osteoarthritis and bunions. So if you see something and you see they have 45 degrees of toe out when they're walking or running down the road, we're going to alter it with verbal cueing. An internal focus that is visual is, imagine and visualise your foot is the front tire on your car. Keep it pointing straight down the road. That's the image, the analogy. An auditory internal focus is listen to the verbal cue of the coach or the therapist, yep, you got it; no, dampen it, it's too much; or you've got to put more effort into it. A kinaesthetic cue would be push your heel outward or turn your toe inward and point it straight ahead. An external focus visual would be to put a marker on the ground, on the treadmill, on the road, a line. Line your foot up with it. It's external to the body. An auditory is say out loud, when you're walking, turn your foot inward, turn your foot inward. A kinaesthetic would be to tap the muscles on the front of the hip because it's likely they're doing it up at the hip. Use this muscle, turn it in. Or put it on their butt and say, you should feel some stretching in there as a verbal cue.


So there's a fair amount of literature that knee osteoarthritis, an automatic compensation is to toe out. And so we're going to say, I want you to toe in. Why do they toe out? Well, the work of Hunt and his colleagues have come up with a biomechanical explanation. In this illustration, we're looking at the schematic of a right leg from the front because you can see the orientation of the fibula is on that side. And in figure A, the foot is lined up straight ahead, less than 15 degrees of toe out. And then figure B the figure is toed out more than 15 degrees. The black vertical line is the ground reaction force, the dotted line is the distance from the ground reaction force to the knee joint axis. And that is a measure of what's called knee adduction moment or a varus moment or movement of the knee, which is highly associated with knee osteoarthritis. So anything we can do to decrease that knee adduction moment is going to decrease the knee pain if they have knee osteoarthritis. So the patient will automatically decrease that distance as in B, by toeing out. Now they have a new knee, where they don't need to do that, we're going to tell them to toe in.  
So there's a fair amount of literature that knee osteoarthritis, an automatic compensation is to toe out. And so we're going to say, I want you to toe in. Why do they toe out? Well, the work of Hunt and his colleagues have come up with a biomechanical explanation. In this illustration, we're looking at the schematic of a right leg from the front because you can see the orientation of the fibula is on that side. And in figure A, the foot is lined up straight ahead, less than 15 degrees of toe out. And then figure B the figure is toed out more than 15 degrees. The black vertical line is the ground reaction force, the dotted line is the distance from the ground reaction force to the knee joint axis. And that is a measure of what's called knee adduction moment or a varus moment or movement of the knee, which is highly associated with knee osteoarthritis. So anything we can do to decrease that knee adduction moment is going to decrease the knee pain if they have knee osteoarthritis. So the patient will automatically decrease that distance as in B, by toeing out. Now they have a new knee, where they don't need to do that, we're going to tell them to toe in.  


So we're going to talk about side effects. So in this example, in this video, she's status post right total knee replacement. She's doing the dance step to nowhere with more than 15 degrees of toe out in the right leg. I tell her, point your toe straight ahead and do it this way. What's going to be the side effect of doing that? It's going to decrease knee adduction moment and that's fine, but the potential adverse effect when you toe in, you increase the knee flexion moment. Now, acute or early in the total joint replacement, they're going to have a weak quadriceps and they may not feel comfortable toeing in. And they may feel a little more pain in the knee when they toe in, as they're recovering from the total knee replacement. So you can be aware of that and if they say, you do the dance step to nowhere, point your foot straight ahead. And they say, doc, I'm getting more knee pain, or then you need to ask them, is it in the joint or is it in your thigh muscle? Is it a fatigue of the quadriceps? That's something I want you to work through. That's how you can begin to problem solve.
increased muscle fatigue and soreness. You're going to expect them to get sore in their gluteal muscles. Now, if they come to you complaining of gluteal tendinopathy pain, the discomfort they're going to feel from the intervention is going to be in the same location that they came to you complaining of a symptom. So you need to have that discussion and talk about the nature of the pain. Is this the burning pain that keeps you awake at night? Or is this a good muscle soreness that you get from doing exercise and working through?
 
The last gait deviation I want to talk about is the common one of lateral pelvic drop, contralateral pelvic drop. The pain syndromes associated with that are back pain, hip labral problems, gluteal tendinopathy, piriformis syndrome, patellofemoral arthralgia, IT band syndrome, medial tibial stress, ankle pain, Achilles pain, and plantar heel pain syndrome. So what are the verbal cues that we can use that are internal focus of attention? A visual would be, imagine your pelvis is a bucket full of water, don't let that spill out. Keep it level. Auditory would be, imagine your pelvis is a hand bell, quiet the clang. That's an analogy and an image. Kinaesthetic internal, touch your hip muscle I want you to engage and use that muscle when you're doing the dance step to nowhere and when you walk this way. An external focus would be walk towards the mirror and watch your belt line and keep it more level. Or use a laser light on the contralateral hip and put a target in front of them. An auditory external focus would be listen to your foot strike and make it symmetric and smooth. Kinaesthetic would be a hip spica brace, a neoprene sleeve, a non-elastic strapping technique or elastic kinesio-strapping.
 
So what are the potential side effects of altering your lateral pelvic drop? This is where I want to use the example of increased muscle fatigue and soreness. You're going to expect them to get sore in their gluteal muscles. Now, if they come to you complaining of gluteal tendinopathy pain, the discomfort they're going to feel from the intervention is going to be in the same location that they came to you complaining of a symptom. So you need to have that discussion and talk about the nature of the pain. Is this the burning pain that keeps you awake at night? Or is this a good muscle soreness that you get from doing exercise and working through? So the hypothesis is if explicit alteration of gait deviation of too long a step, what are the muscles that are going to be a sore or fatigued? It's the thigh, maybe the calf muscles. Excuse me, that was for too long a step. If you take shorter steps, they're going to feel more stretch and more strained in the calf and thigh. Lateral pelvic drop is going to be the gluteal muscles. If they have prolonged heel contact or late heel off, they're going to feel soreness in the foot because now they're going to use the front of the foot and fatigue in the calf muscles, maybe the gluteal muscles, because there's a synergy between calf and glutes. And if they're excessive out-toeing and they're going to in-toe, they're going to feel a fatigue in the internal rotators of the hip and stretch in the lateral rotators of the hip.


== Resources  ==
== Resources  ==

Revision as of 03:52, 9 August 2022

Original Editor - Stacy Schiurring based on the course by Damien Howell

Top Contributors - Stacy Schiurring, Kim Jackson, Jess Bell and Lucinda hampton

Introduction[edit | edit source]

Welcome to the last module for gait analysis and gait training. This module is entitled Side Effects of Verbal Cueing and Interventions to Alter Gait Deviations. I'm going to use this module to synthesise the previous 12 modules on gait analysis and gait training, where you see a gait deviation and we do something, you intervene using the mechanisms of motor learning and criteria for good verbal cueing of external focus of attention and paying attention to the sensory preference of your client or your patient. And then discussing being proactive in terms of identifying and recognising potential side effects of whatever intervention that we choose.

Intervention Side Effects[edit | edit source]

Definitions:

A side effect is typically an undesirable or unintended consequence of an intervention. [1]

A nocebo effect occurs when a patient's negative expectations of a treatment causes the treatment to have a more negative outcome than it otherwise would have.[2]

A placebo effect is the tendency of a medication or treatment, even an inert or ineffective one, to exhibit results simply because the recipient believes that it will work.[3]

Evert Verhagen et al. in 2014 pointed out, when it comes to intervening with physical activity, exercise, and gait training, when we compare that to intervening with medicine, the adverse effects or the side effects or the unintended consequences, we tend to ignore them or don't pay attention to them.

The risk of adverse effects when prescribing rehabilitation interventions such as physical activity, exercise, or gait training are low but they are not nonexistent. Clinicians should be proactive in sharing potential side effects with patients[1] as part of treatment informed consistent.

Possible clinical outcomes of sharing potential side effects:[1]

  1. Increasing the level of engagement with patients
  2. Can facilitate timely adjustments for chosen interventions
  3. May itself induce unintended or adverse effects through the nocebo effects

A rehabilitation professional can use clinical reasoning to create a working hypothesis to try and improve unintended consequences of therapeutic interventions.

The three common side effects of altering a gait deviation:[1]

  1. Increased energy expenditure, it can be physically taxing to walk and run in a new way
  2. Increased cognitive demand, the brain must work harder to meet the task
  3. Increased muscle fatigue and soreness for utilising muscles in a novel way

Gait Deviations[edit | edit source]

Gait deviation Related musculoskeletal

pain syndromes

Sensory System Internal focus of attention: Cue, Prompt, Feedback External focus of attention: Cue, Prompt, Feedback Potential side effects
Too long a step or stride length
  • Back pain
  • Anterior hip pain
  • Lateral knee pain
  • IT band syndrome
  • Anterior knee pain
  • Patellofemoral arthralgia
  • Medial tibial stress syndrome
  • Stress fractures
  • Achilles pain
  • Plantar heel pain syndrome
 Visual Imaging/visualiSe walking on hot sand Use laser light target for shorter steps Making step length shorter could result in
  • increased energy expenditure[4]
Auditory "Walk like you are sneaking up on someone" Listen to metronome music at appropriate cadence beats/minute
Kinesthetic Tactile Take shorter steps more steps/minute Wearable with vibratory feedback at appropriate cadence
Late/delayed heel off
  • Anterior hip pain
  • Anterior knee pain
  • Patellofemoral arthralgia
  • Anterior ankle pain
  • Achilles pain (due to stretch weakness)
  • Plantar heel pain syndrome
 Visual Imagine/see yourself propel up and forward Walk towards mirror watch top of head, laser light target Cognitive overload
Auditory “spring in your step” Listen to verbal cues provided: “yes”; “dampen it”; “need more effort”
Kinesthetic Tactile Feel heel lift off ground sooner Use of elastic tape
Too much toe out

(more than 15 to 20 degrees of the foot progression angle)

  • Hip osteoarthritis (OA)
  • Knee OA
  • Can continue after a total joint replacement
  • Patellofemoral arthralgia
  • medial tibial stress syndrome
  • Achilles pain
  • Plantar heel pain syndrome
  • pain on the ball of the foot
  • Metatarsalgia
  • hallux limitus
  • Great toe OA
  • Bunions
 Visual Visualise your foot as a front car tire, keep it straight down road Align foot with tape or line on ground
  • Potential adverse effect with intention increase of toe in is a decreased knee adduction moment and an increased knee flexion moment
  • For patients status post total knee replacements with weak quadriceps, may experience knee pain
Auditory Listen to verbal cues provided: “yes”; “dampen it”; “need more effort” Say out loud "turn foot inward"
Kinesthetic Tactile Push heel outward or turn toe inward Touch or tap the muscles on front of hip, "use this muscle"
Lateral pelvic drop, contralateral pelvic drop
  • Back pain
  • Hip labral problems
  • Gluteal tendinopathy
  • Piriformis syndrome
  • Patellofemoral arthralgia
  • IT band syndrome
  • Medial tibial stress
  • Ankle pain
  • Achilles pain
  • Plantar heel pain syndrome
 Visual Imagine pelvis is bucket of water, don’t let water spill out
  • Walk towards mirror, watch belt and keep it level
  • Laser light target
 Muscle fatigue and soreness
Auditory "Image pelvis is bell, quiet the clang of the bell" Listen for foot strike make sound symmetrical and rhythmic
Kinesthetic Tactile Touch hand to gluteal muscles, "engage this muscle"
  • Hip spica brace
  • Neoprene sleeve
  • Nonelastic or elastic strapping of hip


Cognitive overload can occur when a person is being challenged mentally by the therapeutic interventions. They are processing too much information or too many tasks, and it adversely affects their motor learning process. The rehabilitation professional can modify this overload by: (1) discontinuing the intervention, (2) continue the intervention and encourage the patient through the task, (3) modify the task from the whole into smaller steps or parts, (4) or modify the intervention by switching the sensory preference of the verbal cue being provided to the patient.[1]

So there's a fair amount of literature that knee osteoarthritis, an automatic compensation is to toe out. And so we're going to say, I want you to toe in. Why do they toe out? Well, the work of Hunt and his colleagues have come up with a biomechanical explanation. In this illustration, we're looking at the schematic of a right leg from the front because you can see the orientation of the fibula is on that side. And in figure A, the foot is lined up straight ahead, less than 15 degrees of toe out. And then figure B the figure is toed out more than 15 degrees. The black vertical line is the ground reaction force, the dotted line is the distance from the ground reaction force to the knee joint axis. And that is a measure of what's called knee adduction moment or a varus moment or movement of the knee, which is highly associated with knee osteoarthritis. So anything we can do to decrease that knee adduction moment is going to decrease the knee pain if they have knee osteoarthritis. So the patient will automatically decrease that distance as in B, by toeing out. Now they have a new knee, where they don't need to do that, we're going to tell them to toe in.

increased muscle fatigue and soreness. You're going to expect them to get sore in their gluteal muscles. Now, if they come to you complaining of gluteal tendinopathy pain, the discomfort they're going to feel from the intervention is going to be in the same location that they came to you complaining of a symptom. So you need to have that discussion and talk about the nature of the pain. Is this the burning pain that keeps you awake at night? Or is this a good muscle soreness that you get from doing exercise and working through?

Resources[edit | edit source]

Clinical Resources:

  • find the two handouts from the lecture


Optional Additional Reading:

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Howell, D. Gait Analysis. Side Effects of Verbal Cueing & Interventions to Alter Gait Deviations. Physioplus. 2022.
  2. ↑ Wikipedia. Nocebo. Available from: https://en.wikipedia.org/wiki/Nocebo (accessed 06/08/2022).
  3. ↑ Wikipedia. Placebo. Available from: https://en.wikipedia.org/wiki/Placebo_effect_(disambiguation) (accessed 06/08/2022).
  4. ↑ Doyle E, Doyle TL, Bonacci J, Fuller JT. The effectiveness of gait retraining on running kinematics, kinetics, performance, pain, and injury in distance runners: a systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2022 Apr;52(4):192-A5.
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